Honoring Our PACT Act of 2022 (P.L. 117-168): Expansion of Health Care Eligibility and Toxic Exposure Screenings

Honoring Our PACT Act of 2022 (P.L. 117-168): Expansion of Health Care Eligibility and Toxic Exposure Screenings

Honoring Our PACT Act of 2022 (P.L. 117-168): April 19, 2024
Expansion of Health Care Eligibility and Toxic
Sidath Viranga Panangala
Exposure Screenings
Specialist in Veterans
Policy
Numerous legislative measures were introduced in the 117th Congress to address the health and

disability compensation concerns of veterans potentially exposed to toxic substances during
military service. The culmination of this effort was the Sergeant First Class Heath Robinson

Honoring our Promise to Address Comprehensive Toxics Act of 2022, or the Honoring our
PACT Act of 2022 (P.L. 117-168), which President Biden signed into law on August 20, 2022. The Honoring our PACT Act
of 2022 contains nine titles. As part of a series of CRS reports on various provisions in the Honoring our PACT Act of 2022,
this report focuses on Title I and Section 603 of Title IV.
Title I (Conceding Our Veterans’ Exposure Now and Necessitating Training Act of 2022, or the COVENANT Act of 2022)
of the Honoring our PACT Act of 2022 expands health care eligibility via two major pathways. The first expands access to
health care through the Veterans Health Administration (VHA) for specific categories of veterans exposed to toxic
substances, and the second expands the health care enrollment period for certain veterans of combat service. For purposes of
this report, unless otherwise specified, the Secretary refers to the Secretary of Veterans Affairs (VA).
The first pathway includes three different authorities:
1. The act authorizes the Secretary to provide hospital care (including mental health services and counseling), medical
services, and nursing home care for any illness, unless there is insufficient medical evidence to conclude that the
illness is attributable to such service, to a veteran who participated in a “toxic exposure risk activity” while serving
on active duty, active duty for training, or inactive duty training. A “toxic exposure risk activity” means any activity
that requires a corresponding entry in the Individual Longitudinal Exposure Record (ILER) of the veteran who
carried out the activity, or any activity that the Secretary “determines qualifies for the purposes of this subsection”
(e.g., hospital care, medical services, and nursing home care) to reasonably protect the health of veterans.
2. The act authorizes the Secretary to provide hospital care (including mental health services and counseling), medical
services, and nursing home care for any illness, unless there is insufficient medical evidence to conclude that the
illness is attributable to such service, to any veteran who, on or after August 2, 1990, performed active military,
naval, air, or space service while assigned to a duty station in, including airspace above, Bahrain, Iraq, Kuwait,
Oman, Qatar, Saudi Arabia, Somalia, or United Arab Emirates; or who, on or after September 11, 2001, performed
active military, naval, air, or space service while assigned to a duty station in, including airspace above,
Afghanistan, Djibouti, Egypt, Jordan, Lebanon, Syria, Yemen, Uzbekistan, the Philippines, or any other country
determined by the Secretary.
3. The act authorizes the Secretary to provide hospital care (including mental health services and counseling), medical
services, and nursing home care for any illness, unless there is insufficient medical evidence to conclude that the
illness is attributable to such service, to a veteran who was deployed for any of the following contingency
operations: Operation Enduring Freedom, Operation Freedom’s Sentinel, Operation Iraqi Freedom, Operation New
Dawn, Operation Inherent Resolve, or Resolute Support Mission.
On February 26, 2024, VA announced that it will be eliminating the phase-in enrollment dates under Section 103 of the
Honoring our PACT Act of 2022 (that is, between October 1, 2024, and October 1, 2032) of the above three statutory
categories, and accepting and processing applications for enrollment in the VA health care system from all eligible veterans
under the PACT Act beginning March 5, 2024.
The second pathway expands the period of eligibility for enrollment in the VA health care system for certain combat service
veterans. The act extends the period of enrollment in the VA health care system from 5 to 10 years. Veterans who served
between September 11, 2001, and before October 1, 2013, but who prior to the act could not enroll during the five-year
period of post-discharge eligibility, were granted an additional one-year period of enrollment eligibility beginning on October
1, 2022. Furthermore, the act clarified that service in the “Persian Gulf War” includes any veteran who, during such period of
service, received the Armed Forces Expeditionary Medal, Service Specific Expeditionary Medal, Combat Era Specific
Expeditionary Medal, Campaign Specific Medal, or any other combat theater award established by a federal statute or an
executive order. The enrollment expansion became effective on October 1, 2022. The above criteria also applies to National
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Honoring our PACT Act of 2022 (P.L. 117-168)

Guard and Reserve personnel who were called to active duty by federal executive order and who served in a theater of
combat operations after November 11, 1998.
Section 603 of Title VI (Fairly Assessing Service-related Toxic Exposure Residuals Presumptions Act of 2022, or the
FASTER Presumption Act of 2022) required VA to implement toxic exposure screening of all enrolled veterans to help
determine potential toxic exposures during active military, naval, air, or space service. VA implemented toxic exposure
screenings on November 8, 2022.
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Contents
Introduction ..................................................................................................................................... 1
Brief Legislative History ................................................................................................................. 4
Cost of War Toxic Exposures Fund (TEF) ...................................................................................... 6
Expansion of Health Care Eligibility .............................................................................................. 7
Background ............................................................................................................................... 7
Health Care Eligibility for Toxic Exposures ............................................................................. 9
Vietnam-Era, Herbicide-Exposed Veterans ......................................................................... 9
Radiation-Exposed Veterans .............................................................................................. 11
Persian Gulf War Veterans ................................................................................................ 12
Combat‐Theater Veterans .................................................................................................. 13
Veterans Who Participated in Operation Shipboard Hazard and Defense
(SHAD)/Project 112 Tests ............................................................................................. 14
Camp Lejeune Veterans .................................................................................................... 15
Veterans Who Participated in a Toxic Exposure Risk Activity (TERA) ........................... 18
Veterans Who Served in a Specific Duty Station .............................................................. 18
Veterans Deployed in Support of Contingency Operations .............................................. 19
Elimination of the Phase-In Dates for New Cohorts of Toxic Exposed Veterans ................... 21
Toxic Exposure Screenings of Veterans ........................................................................................ 23
Honoring our PACT Act Performance Dashboard ........................................................................ 28

Figures
Figure 1. High-Level Overview of Eligibility Pathways for Toxic Exposed Veterans .................. 16
Figure 2. Expansion of Health Care for Specific Categories of Toxic-Exposed Veterans
and Veterans in Specific Contingency Operations with Statutory Phase-In Dates ..................... 20
Figure 3. Health Care for Specific Categories of Toxic-Exposed Veterans and Veterans in
Specific Contingency Operations with Modified Phase-In Date of March 5, 2024 ................... 23
Figure 4. Toxic Exposure Screening Tool Clinical Reminder ....................................................... 25
Figure 5. Overview of Toxic Exposure Screening Workflow ........................................................ 27

Contacts
Author Information ........................................................................................................................ 28

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Introduction
On August 10, 2022, President Biden signed into law the Sergeant First Class Heath Robinson
Honoring our Promise to Address Comprehensive Toxics Act of 2022, or the Honoring our PACT
Act of 2022 (P.L. 117-168). The act marked the culmination of a legislative effort, spanning
several congresses, to comprehensively address health care eligibility and disability compensation
policies for veterans exposed to a wide variety of occupational and environmental hazards during
military service. Over the years, as evidenced by numerous Senate and House Veterans’ Affairs
Committee hearings and studies,1 Congress and the Department of Veterans Affairs (VA) have
grappled with how to provide disability compensation and eligibility for health care to veterans
with illnesses and disabilities related to, or possibly related to, environmental or occupational
exposures.
Providing this type of disability compensation and health care eligibility to veterans can be
challenging; for example, when the scientific evidence is incomplete, when the association
between environmental exposure and illness is unclear, and when other factors (e.g., natural
aging, family history, and lifestyle habits) might contribute to the illness or disability. In other
words, incorporating “science into difficult and contentious veteran compensation policy
decisions”2 is hard, especially when considering environmental exposures during deployment and
“latent diseases allegedly associated with exposures many years earlier.”3 Given these challenges,
Congress “has taken a piecemeal approach to addressing military exposures.”4
From time to time, Congress has passed legislation related to care and benefits for former
prisoners of war, service in Vietnam, exposure to ionizing radiation, service during the Persian
Gulf War, contaminated drinking water at Camp Lejeune North Carolina, and Blue Water Navy
Vietnam veterans, among other legislative efforts.
In response to mounting concerns about the use of open burn pits during Operation Iraqi Freedom
(OIF) in Iraq and Operation Enduring Freedom (OEF) in Afghanistan, and the potential impacts
on the health of veterans who served at or near open burn pit sites in Afghanistan and the

1 In 2007, the Veterans’ Disability Benefits Commission (established in accordance with P.L. 108-136 as, amended by
P.L. 109-163, see 38 U.S.C. §1101 notes) examined benefits for veterans exposed to environmental/occupational
hazards and—because “an increasing proportion of benefits is paid through a presumptive decision-making process”—
tasked the then-Institute of Medicine (IOM; since 2015 known as the National Academy of Medicine [NAM], part of
the National Academies of Sciences, Engineering, and Medicine [NASEM]) to examine the presumptive
decisionmaking process and “recommend a framework that would rely on scientific principles.” Veterans’ Disability
Benefits Commission, Honoring the Call to Duty: Veterans’ Disability Benefits in the 21st Century, Washington, DC,
October 2007, pp. 18, 111; U.S. Congress, House Committee on Government Reform, Subcommittee on National
Security, Veterans Affairs and International Relations, Gulf War Veterans: Linking Exposures, 106th Cong., 2nd sess.,
September 27, 2000 (Washington: GPO, 2001); U.S. Congress, Senate Committee on Veterans’ Affairs, Military
Exposures: The Continuing Challenges of Care and Compensation, 107th Cong., 2nd sess., July 10, 2002, S.Hrg. 107-
792 (Washington: GPO, 2002); U.S. Congress, Senate Committee on Veterans’ Affairs, VA/DOD Response To Certain
Military Exposures, 111th Cong., 1st sess., October 8, 2009, S.Hrg. 111-437 (Washington: GPO, 2010); U.S. Congress,
Senate Committee on Veterans’ Affairs, Examining The Impact of Exposure to Toxic Chemicals on Veterans and the
VA’s Response, 114th Cong., 1st sess., September 29, 2015, S.Hrg. 114-371 (Washington: GPO, 2016).
2 Mark Brown, “The Role of Science in Department of Veterans Affairs Disability Compensation Policies for
Environmental and Occupational Illnesses and Injuries,” Journal of Law and Policy, vol. 13, no. 2 (2005), p. 606.
3 Mark Brown, “The Role of Science in Department of Veterans Affairs Disability Compensation Policies for
Environmental and Occupational Illnesses and Injuries,” Journal of Law and Policy, vol. 13, no. 2 (2005), p. 606.
4 U.S. Congress, Senate Committee on Veterans’ Affairs, Examination of Exposures to Environmental Hazards During
Military Service And Health Care For Camp Lejeune And Atsugi Naval Air Facility Veterans And Their Families Act
Of 2010, report to accompany S. 3378, 111th Cong., 2nd sess., May 17, 2010, S.Rept. 111-189, p. 2.
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Southwest Asia theater of operations,5 Congress passed legislation to study the potential health
effects associated with exposure to open burn pit emissions during deployment. The earliest
legislation to do so was the Dignified Burial and Other Veterans’ Benefits Improvement Act of
2012 (P.L. 112-260), which authorized VA to establish a registry of veterans and current
servicemembers who may have been exposed to “toxic airborne chemicals and fumes caused by
open burn pits”6 within one year after enactment. Moreover, H.Rept. 115-929 to accompany the
Energy and Water, Legislative Branch, and Military Construction and Veterans Affairs
Appropriations Act, 2019 (H.R. 5895; P.L. 115-244), required VA to rename the Airborne Hazards
Center of Excellence (AHCE) at the War Related Illness and Injury Study Center as the Airborne
Hazards and Burn Pits Center of Excellence, and to focus on clinical, translation research, and
education pertaining to airborne hazards and open burn pit exposure-related concerns of
veterans.7 In 2009, VA requested the then-Institute of Medicine (IOM; now the National Academy
of Medicine of the National Academies of Sciences, Engineering, and Medicine [NASEM]) to
assess “the potential long-term health effects of exposure to burn pits in Iraq and Afghanistan,”
and to examine the feasibility and design of a long-term epidemiological study of veterans
exposed to burn pit emissions.8 NASEM issued its report in October 2011. According to the
report findings, among other conclusions,
... service in Iraq or Afghanistan—that is, a broader consideration of air pollution than
exposure only to burn pit emissions—might be associated with long-term health effects,
particularly in highly exposed populations (such as those who worked at the burn pit) or
susceptible populations (for example, those who have asthma), mainly because of the high
ambient concentrations of PM [particulate matter] from both natural and anthropogenic,
including military, sources. If that broader exposure to air pollution turns out to be
sufficiently high, potentially related health effects of concern are respiratory and
cardiovascular effects and cancer.9
The NASEM report further recommended a well-designed epidemiologic study of the potential
health effects of environmental exposures among U.S. military personnel and veterans who were
deployed at burn pit sites. It further noted that determining the incidence of chronic diseases or
cancers with long latency periods would require tracking study subjects for many years.10
The Dignified Burial and Other Veterans’ Benefits Improvement Act of 2012 (P.L. 112-260)
further required independent assessments of the Airborne Hazards and Open Burn Pit Registry
(AHOBPR) that was established by VA in June 2014 and a follow-up report not later than five
years after completion of the initial report.11 VA contracted with NASEM to evaluate the registry.

5 The VA defines the Southwest Asia theater of operations as “Iraq, Kuwait, Saudi Arabia, the neutral zone between
Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the
Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations” (38 C.F.R. §3.317(e)(2)). Also see
“What’s included in the Southwest Asia theater of military operations?” https://www.va.gov/disability/eligibility/
hazardous-materials-exposure/gulf-war-illness-southwest-asia/; and https://www.publichealth.va.gov/exposures/
gulfwar/military-service.asp.
6 38 U.S.C. §527 note.
7 In 2013, VA established the Airborne Hazards Center of Excellence (AHCE) at the New Jersey War Related Illness
and Injury Study Center.
8 National Academies of Science, Engineering, and Medicine, Long-Term Health Consequences of Exposure to Burn
Pits in Iraq and Afghanistan, October 31, 2011, National Academies Press, Washington, DC, p. 13.
9 National Academies of Science, Engineering, and Medicine, Long-Term Health Consequences of Exposure to Burn
Pits in Iraq and Afghanistan, October 31, 2011, National Academies Press, Washington, DC, p. 7.
10 National Academies of Science, Engineering, and Medicine, Long-Term Health Consequences of Exposure to Burn
Pits in Iraq and Afghanistan, October 31, 2011, National Academies Press, Washington, DC, p. 117.
11 Department of Veterans Affairs, “Establishment of the Airborne Hazards and Open Burn Pit Registry,” 79 Federal
Register 36142-36144, June 25, 2014.
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The law required that the assessment include, among other things, “recommendations regarding
the most effective and prudent means of addressing the medical needs of eligible individuals with
respect to conditions that are likely to result from exposure to open burn pits”12 Among other
findings, the initial report “concluded that the exposure data are of insufficient quality or
reliability to make them useful in anything other than the most general assessments of exposure
potential.”13 As required by P.L. 112-260, NASEM conducted another reassessment of the
AHOBPR, and its findings were released in October 2022. The findings concluded that “the
stated registry purposes of ‘research about potential health effects of airborne hazards’ and
conducting population health surveillance are unattainable, that data collection to meet these
purposes is not helpful, and that efforts to address these important functions could be pursued in
other, more effective ways.” NASEM recommended that VA initiate a new phase for the
AHOBPR.14
In September 2018, VA requested NASEM to study the health effects of airborne hazards and
respiratory health outcomes in veterans who participated in military operations in Southwest Asia.
The NASEM study committee developed a list of 27 respiratory health outcomes to review, such
as respiratory cancers, asthma, chronic bronchitis, chronic obstructive pulmonary disease,
emphysema, chronic persistent cough, shortness of breath (dyspnea), and wheezing, and released
its findings in September 2020. Among its findings, the NASEM study committee concluded that
of the 27 respiratory health outcomes examined, only chronic persistent cough, shortness of
breath (dyspnea), and wheezing met the criteria for limited or suggestive evidence of an
association,15 and that the remaining 24 conditions had inadequate or insufficient evidence to
determine an association.16 In testimony before the House Veterans’ Affairs Subcommittee on
Disability Assistance and Memorial Affairs, NASEM stated
It is clear that military personnel and veterans are experiencing respiratory health problems,
and our committee [Committee on the Respiratory Health Effects of Airborne Hazards
Exposure in the Southwest Asia Theater of Military Operations] wishes to emphasize that
these findings do not mean that there is no association between service in the Southwest
Asia theater and these conditions. Instead, the committee found that the available
epidemiologic evidence does not allow a definitive determination to be made about any
potential association.17

12 P.L. 112-260, Title II, Section 201(b)(iii). National Academies of Sciences, Engineering, and Medicine, Assessment
of the Department of Veterans Affairs Airborne Hazards and Open Burn Pit Registry, February 2017, National
Academies Press, Washington, DC, p. 13.
13 National Academies of Sciences, Engineering, and Medicine, Assessment of the Department of Veterans Affairs
Airborne Hazards and Open Burn Pit Registry, February 2017, National Academies Press, Washington, DC, p. 5.
14 National Academies of Sciences, Engineering, and Medicine, Reassessment of the Department of Veterans Affairs
Airborne Hazards and Open Burn Pit Registry, October 14, 2022, The National Academies Press, Washington, DC, p.
3.
15 NASEM defines limited or suggestive evidence of an association as an outcome for which “the evidence must
suggest an association between an in-theater exposure and a respiratory outcome in studies of humans, but it can be
limited by an inability to confidently rule out chance, bias, or confounding.” (Source: Respiratory Health Effects of
Airborne Hazards Exposures in the Southwest Asia Theater of Military Operations, a briefing on a National Academies
report to congressional staff, September 10, 2020).
16 National Academies of Sciences, Engineering, and Medicine. Respiratory Health Effects of Airborne Hazards
Exposures in the Southwest Asia Theater of Military Operations. September 11, 2020, The National Academies Press,
Washington, DC, pp. 5-6. Also see Department of Veterans Affairs, “Presumptive Service Connection for Respiratory
Conditions Due to Exposure to Particulate Matter,” 86 Federal Register 42724-42733, August 5, 2021.
17 U.S. Congress, House Committee on Veterans’ Affairs, Subcommittee on Disability Assistance and Memorial
Affairs, Toxic Exposures: Examining Airborne Hazards in the Southwest Asia Theater of Military Operations,
Statement of Dr. Sverre Vedal, Professor Emeritus, Department of Environmental and Occupational Health Sciences
University of Washington School of Public Health, 116th Cong., 2nd sess., September 23, 2020.
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Frustrated by a persistent lack of scientific evidence to link certain diseases or conditions with
environment exposures during military service, veterans turned to Congress for legislation that
would enable them to obtain VA medical care and disability compensation.
Brief Legislative History
At the start of the 117th Congress, the House and Senate Veterans’ Affairs Committees (HVAC
and SVAC, respectively) made veterans’ exposure to toxic substances a legislative priority.18
Although numerous measures were introduced in the 117th Congress to address the health and
disability compensation concerns of veterans potentially exposed to toxic substances, the HVAC
and SVAC began drafting legislation that incorporated various provisions of multiple stand-alone
bills.19
On June 17, 2021, then-Chairman Mark Takano of HVAC introduced the Honoring our Promise
to Address Comprehensive Toxics Act of 2021, or the Honoring our PACT Act of 2021 (H.R.
3967). A markup of the bill was held on June 24, 2021. The text of H.R. 3967, as ordered reported
(H.Rept. 117-249 Part 1) by the Committee on Veterans’ Affairs, with modifications, was then
included in House Rules Committee Print 117-33. Following floor debate, the House passed an
amended version of the bill on March 3, 2022.20 On October 19, 2021, Chairman Jon Tester of
SVAC reported the Comprehensive and Overdue Support for Troops of War Act of 2021, or the
COST of War Act of 2021 (S. 3003), to the Senate. In the meantime, SVAC Chairman Jon Tester
and ranking member Jerry Moran decided on a “three-step approach” to address issues pertaining
to health care, disability compensation, and presumptive service-connection.21 To address health

18 House Committee on Veterans’ Affairs, “Chairman Takano Announces Priorities for the 117th Congress,” press
release, February 22, 2021, https://democrats-veterans.house.gov/news/press-releases/chairman-takano-announces-
priorities-for-the-117th-congress; House Committee on Veterans’ Affairs, “Ranking Member Bost Spearheads House
Effort to Address Toxic Exposures, Introduces TEAM Act with Senator Tillis,” press release, March 23, 2021,
https://veterans.house.gov/news/documentsingle.aspx?DocumentID=5800; Senate Committee on Veterans’ Affairs,
“Tester to Take Gavel as Chairman of the Senate Veterans’ Affairs Committee,” press release, January 26, 2021,
https://www.veterans.senate.gov/2021/1/tester-to-take-gavel-as-chairman-of-the-senate-veterans-affairs-committee-;
Senate Committee on Veterans’ Affairs, “Sen. Moran Confirmed as Ranking Member, Announces Priorities for the
117th Congress,” press release, February 9, 2021, https://www.veterans.senate.gov/2021/2/sen-moran-confirmed-as-
ranking-member-announces-priorities-for-the-117th-congress.
19 Some of these bills included, the following (in no specific order): S. 437, Veterans Burn Pits Exposure Recognition
Act of 2021; H.R. 1585, Mark Takai Atomic Veterans Healthcare Parity Act; S. 565, Mark Takai Atomic Veterans
Healthcare Parity Act of 2021; S. 657, a bill to modify the presumption of service-connection for Veterans who were
exposed to herbicide agents while serving in the Armed Forces in Thailand during the Vietnam era; H.R. 1972, Fair
Care for Vietnam Veterans Act of 2021; S. 927, TEAM Act; H.R. 2127, TEAM Act; S. 952, Presumptive Benefits for
War Fighters Exposed to Burn Pits and Other Toxins Act of 2021; H.R. 2372, Presumptive Benefits for War Fighters
Exposed to Burn Pits and Other Toxins Act of 2021; S. 1039, To amend title 38, United States Code, to improve
compensation for disabilities occurring in Persian Gulf War veterans, and for other purposes; H.R. 2192, Camp Lejeune
Justice Act of 2021; H.R. 2268, Keeping Our Promises Act; H.R. 2368, COVENANT Act of 2021; H.R. 2436,
Veterans Burn Pits Exposure Recognition Act of 2021; H.R. 2569, Veterans Agent Orange Exposure Equity Act; H.R.
2601, SFC Heath Robinson Burn Pit Transparency Act; S. 1188, SFC Heath Robinson Burn Pit Transparency Act; H.R.
2607, FASTER Presumptions Act; S. 1151, Palomares Veterans Act of 2021; H.R. 2825, Fort McClellan Health
Registry Act; H.R. 6659, Health Care for Burn Pit Veterans Act; H.R. 5599, Burn Pit PROMISE Act; S. 1393, Toxic
Exposure Training Act of 2021; S. 3003, COST of War Act of 2021; S. 3541, Health Care for Burn Pit Veterans Act;
and H.R. 3967, Honoring our PACT Act of 2022. This is not an exhaustive list of the measures introduced.
20 “Honoring Our Promise to Address Comprehensive Toxics Act of 2021,” Congressional Record, daily edition, vol.
168, no. 38 (March 2, 2022), pp. H1219-H1246.
21 Senate Committee on Veterans’ Affairs, “Tester, Moran Introduce Landmark Bill to Provide Health Care for Post-
9/11 Toxic-Exposed Veterans,” press release, February 1, 2022, https://www.veterans.senate.gov/newsroom/majority-
news/tester-moran-introduce-landmark-bill-to-provide-health-care-for-post-9/11-toxic-exposed-veterans; Senate
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care eligibility as a first step, on February 1, 2022, the chairman and ranking member introduced
the Health Care for Burn Pit Veterans Act (S. 3541), which passed the Senate by unanimous
consent on February 16, 2022. Compared with the COST of War Act of 2021 (S. 3003), the
Health Care for Burn Pit Veterans Act (S. 3541) focused on extending the period of enrollment in
the VA health care system for veterans who served in a theater of combat operations. As Senator
Tester stated during Senate consideration of S. 3541, “It expands the screening period of
healthcare eligibility for combat veterans who served after September 11, 2001, from 5 years to
10,” and “provides an open enrollment period for any post-9/11 combat veteran who is more than
10 years from separation.”22
On May 24, 2022, SVAC Chairman Jon Tester and ranking member Jerry Moran released the text
of the SVAC version of the Sergeant First Class Heath Robinson Honoring Our Promise to
Address Comprehensive Toxics (PACT) Act of 2022 that addressed the latter two steps and
included provisions related to health care, disability compensation, and presumptive service-
connection among other provisions.23 On June 8, 2022, the text of the measure was proposed by
Senator Tester as S.Amdt. 5051 to H.R. 3967,24 and it passed the Senate on June 16, 2022.25
Among other provisions, the Senate-passed version included several provisions that would affect
VA employee compensation, including the authority to buy out the service contracts of health care
professionals to whom VA has offered employment at rural or highly rural VA facilities. These
service contract buyouts were to be exempt from taxation. Since the Origination Clause in the
U.S. Constitution (Article 1, Section 7) requires that revenue bills originate in the House and
specifies that the Senate may not propose any amendment that would raise revenue to a House-
passed nonrevenue measure this tax-exempt provision created what is known as a “blue-slipping”
issue.26 The House then took up an unrelated measure previously passed by the Senate (S. 3373),
included the text of the Sergeant First Class Heath Robinson Honoring our Promise to Address
Comprehensive Toxics Act of 2022, excluded the tax-exempt provision, and passed it on July 13,
2022.27 The Senate agreed to the House amendment to S. 3373 and passed the measure on August
2, 2022.28 The bill was signed by the President on August 10, 2022.29

Committee on Veterans Affairs, “Tester, Moran Bill to Expand VA Health Care for Post-9/11 Veterans Unanimously
Clears Senate,” press release, February 16, 2022, https://www.veterans.senate.gov/2022/2/breaking-tester-moran-bill-
to-expand-va-health-care-for-post-9-11-veterans-unanimously-clears-senate.
22 “Health Care for Burn Pit Veterans Act,” Senate Debate Health Care for Burn Pit Veterans, Congressional Record,
vol. 168, no. 31 (February 16, 2022), p. S734.
23 Senate Committee on Veterans’ Affairs, “Tester, Moran Release Text of Historic Bipartisan Toxic Exposure
Legislation,” press release, May 24, 2022, https://www.veterans.senate.gov/2022/5/tester-moran-release-text-of-
historic-bipartisan-toxic-exposure-legislation.
24 “Text of Amendments,” SA 5051. Mr. Tester (for himself and Mr. Moran) submitted an amendment intended to be
proposed by him to the bill H.R. 3967, to improve health care and benefits for veterans exposed to toxic substances,
and for other purposes, Congressional Record, daily edition, vol. 168, no. 97 (June 7, 2022), pp. S2818-S2838.
25 “Honoring Our Promise to Address Comprehensive Toxics Act of 2021,” Congressional Record, daily edition, vol.
168, no. 102 (June 15, 2022), pp. S2947-S2958.
26 For more information on “blue-slipping,” see CRS Report R46556, Blue-Slipping: Enforcing the Origination Clause
in the House of Representatives.
27 “Protecting Our Gold Star Families Education Act,” Congressional Record, daily edition, vol. 168, no.115 (July 13,
2022), pp. H6001-H6025.
28 “Sergeant First Class Heath Robinson Honoring Our Promise to Address Comprehensive Toxics Act of 2022,”
Congressional Record, daily edition, vol. 168, no.129 (August 2, 2022), pp. S3845-S3852.
29 The White House, “Remarks by President Biden at Signing of S. 3373, “The Sergeant First Class Heath Robinson
Honoring Our Promises to Address Comprehensive Toxics (PACT) Act of 2022,” August 10, 2022,
https://www.whitehouse.gov/briefing-room/speeches-remarks/2022/08/10/remarks-by-president-biden-at-signing-of-s-
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Cost of War Toxic Exposures Fund (TEF)
Section 805(a) of the Honoring our PACT Act of 2022 (P.L. 117-168) established the Cost of War
Toxic Exposure Fund (TEF), to be administered by the VA Secretary.30 The act appropriated $500
million for the TEF for FY2022, to remain available until September 30, 2024. The act further
authorizes appropriations (such sums as are necessary) to the fund for FY2023 and each
subsequent fiscal year for costs associated with the delivery of health care associated with
environmental hazards during active military service. Moreover, funds from the TEF are to be
used for costs associated with medical and other research related to environmental hazards, along
with administrative expenses related to benefits, including information technology, benefit claims
processing, and adjudicating appeals from veterans.31 Appropriations provided for the TEF shall
be considered “direct spending” and treated as an “appropriated entitlement” (see text box
below). Furthermore, the fund is exempt from mandatory sequestration provisions in Section
256(h) of Balanced Budget and Emergency Deficit Control Act of 1985 (BBEDCA), as amended.
The Honoring our PACT Act of 2022 also required VA to submit to the Senate and House
Appropriations Committees a spend plan for how the department plans to obligate the $500
million made available under Section 806 of the act. The Consolidated Appropriations Act, 2023
(P.L. 117-328), provided $5.0 billion in mandatory (direct) funding for TEF, to remain available
until September 30, 2027. These funds would be used for new costs associated with eligibility
expansions authorized in the Honoring our PACT Act of 2022 (P.L. 117-168). According to
explanatory statement accompanying the Consolidated Appropriations Act, 2023, there is no shift
in discretionary appropriations to the TEF.32 The Fiscal Responsibility Act (FRA) of 2023 (P.L.
118-5), among other things, provided funding for TEF. The act provided $20.27 billion in
mandatory funding that became available on October 1, 2023, and will remain available until
September 30, 2028, and $24.46 billion, in mandatory funding, which will become available on
October 1, 2024, and will remain available until September 30, 2029.
Based on statute and VA’s Financial Policy documents:
The PACT Act authorizes funds to be appropriated beginning in fiscal year (FY) 2023, and
for each subsequent FY, such sums as are necessary to increase funding over the FY 2021
level for:
• The delivery of Veterans’ health care associated with exposure to environmental
hazards in the active military, naval, air, or space service in programs
administered by the Under Secretary for Health;
• Any expenses incident to the delivery of Veterans’ health care and benefits
associated with exposure to environmental hazards in the active military, naval,
air, or space service, including administrative expenses, such as information

3373-the-sergeant-first-class-heath-robinson-honoring-our-promises-to-address-comprehensive-toxics-pact-act-of-
2022/.
30 38 U.S.C. §324.
31 38 U.S.C. §324 note, “The Secretary of Veterans Affairs may use, from amounts appropriated to the Cost of War
Toxic Exposures Fund ... such amounts as may be necessary to continue the modernization, development, and
expansion of capabilities and capacity of information technology systems and infrastructure of the Veterans Benefits
Administration, including for claims automation, to support expected increased claims processing for newly eligible
veterans pursuant to this Act.”
32 Explanatory Statement Submitted By Mr. Leahy, Chair Of The Senate Committee on Appropriations, Regarding
H.R. 2617, Consolidated Appropriations Act, 2023 Congressional Record, vol. 168, Book II (December 20, 2022), p.
S9235.
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technology and claims processing and appeals, and excluding leases as authorized
or approved under section 8104 of title 38;
• Medical and other research relating to exposure to environmental hazards; and
• Modernization, development, and expansion of capabilities and capacity of
information technology systems and infrastructure of the Veterans Benefits
Administration, including for claims automation, to support expected increased
claims processing for newly eligible Veterans pursuant to section 701.33
What Are Appropriated Entitlements?
While some entitlement programs, such as Medicare and Social Security, are permanently appropriated, some
programs, such as veterans disability compensation and veteran survivor’s Dependency and Indemnity
Compensation (DIC) program and pensions, are annually appropriated entitlements known as appropriated
entitlements. Generally, appropriated entitlements go through the annual appropriations process but are not
subject to annual appropriations decisions of the congressional appropriations committees. “The Appropriations
Committees have little or no discretion as to the amounts they provide. . Even though this funding is included in
an appropriations bil , it is stil considered mandatory spending rather than discretionary spending.” For example,
for veterans’ disability compensation, Congress provides annual funding for tax-free monthly payments to eligible
veterans with disabilities due to disease or injury incurred or aggravated during military service through annual
Military Construction, Veterans Affairs, and Related Agencies Appropriations Act. However, the actual funding
level for disability compensation is determined by the “entitlement” criteria in Chapter 11 of Title 38 of the United
States Code (U.S.C.). The appropriations act appropriates the sums necessary to cover the cost of disability
compensation payments. Congress, during the appropriations process, does not have the discretion to change the
amount spent on the disability compensation program.
Sources: CRS Report RS20129, Entitlements and Appropriated Entitlements in the Federal Budget Process, and CRS
Report R44641, Trends in Mandatory Spending; and CRS Report 98-720 (out of print but available to congressional
clients from the author). Manual on the Federal Budget Process, p. 26; U.S. Congress, Senate Committee on the
Budget, The Congressional Budget Process: An Explanation, committee print, 105th Cong., 2nd sess., December
1998, S.Prt. 105-67 (Washington: GPO, 1998), p. 6; and 38 U.S.C. §§1110, 1121, 1131, and 1141.
Expansion of Health Care Eligibility
Background
The Veterans Health Administration (VHA) of the Department of Veterans Affairs (VA) provides
health care, social services, and other supportive services to veterans and family members of
veterans who meet certain eligibility criteria specified in law and its implementation regulations.
VHA operates the nation’s largest public integrated direct-health care delivery system34 and pays
for care provided to veterans under specified criteria.35 In FY2024, of the approximately 18.25
million veterans living in the United States, an estimated 9.07 million were enrolled in the VA
health care system, and about 6.31 million were estimated to receive care.36

33 VA Financial Policy, “Chapter 12–Toxic Exposure Fund,” https://department.va.gov/financial-policy-documents/
financial-document/chapter-12-toxic-exposures-fund/ (accessed April 9, 2024).
34 Department of Veterans Affairs, FY2025 Congressional Submission, Medical Programs vol. 2 of 5, March 2024, p.
VHA-40.
35 38 U.S.C. §1703.
36 Department of Veterans Affairs, FY2025 Congressional Submission, Medical Programs vol. 2 of 5, March 2024, p.
VHA-40.
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Generally, a veteran has to meet three basic criteria to be eligible for VA health care.37 First, the
veteran must meet the basic eligibility requirement of “veteran status.” That is, a claimant must
first establish veteran status as a condition of eligibility. For VA benefits purposes, a “veteran” is
a person who served in the active military, naval, air, or space service, and who was discharged
or released under conditions other than dishonorable.38 Second, the veteran must meet “active
duty” requirements. Third, the veteran must have served a minimum period of continuous active
duty.
The term “active military, naval, air service or space service” includes “(A) active duty; (B) any
period of active duty for training during which the individual concerned was disabled or dies
from a disease or injury incurred or aggravated in line of duty; (C) and any period of inactive duty
for training during which the individual concerned was disabled or dies (i) from injury incurred
or aggravated in line of duty; or (ii) from an acute myocardial infarction, a cardiac arrest, or a
cerebrovascular accident occurring during such training.”39
In addition to establishing their veteran status, individuals who enlisted in the Armed Forces after
September 7, 1980, as well as those (officer and enlisted) who entered active duty after October
16, 1981, and had (1) not previously completed at least 24 months of continuous active duty
service or (2) not previously been discharged or released from active duty under 10 U.S.C. §1171,
must meet a length-of service requirement. In general, servicemembers must have completed the
shorter of 24 months of continuous active duty service, or the full period for which they were
called or ordered to active duty.40 There are certain exemptions to this requirement. Such
exemptions include, among others, servicemembers (1) discharged for a disability incurred or
aggravated during active-duty service; (2) discharged for a hardship under 10 U.S.C. §1173 or
“early out” under 10 U.S.C. §1171; or (3) who served prior to September 7, 1980.41 National
Guard members and reservists activated under Title 10 of the U.S. Code must also complete the
minimum active duty service requirement.42 For example, a reservist or National Guard member
federally activated to serve in Iraq or Afghanistan for a period of six months who served the
entire period would satisfy the active duty service requirement needed to qualify for veteran
status.
Once these basic requirements are met, veterans fall into two broad health care eligibility
categories. The first eligibility category includes veterans with service-connected disabilities;43
Medal of Honor recipients; Purple Heart recipients; former prisoners of war; veterans exposed to
toxic substances and environmental hazards, such as Agent Orange; and veterans whose
attributable income is not greater than an amount established by a “means test.”44 The second
eligibility category includes veterans who may be eligible to receive care through VA to the extent

37 Department of Veterans Affairs, Veterans Health Administration, Eligibility Determination, VHA DIRECTIVE
1601A.02(4) amended April 5, 2023, pp. 9-10.
38 38 U.S.C. §101(2).
39 38 U.S.C. §101(24).
40 38 U.S.C. §5303A.
41 38 U.S.C. §5303A.
42 Department of Veterans Affairs, Veterans Health Administration, Eligibility Determination, Minimum Active Duty
Service Requirements, VHA DIRECTIVE 1601A.02(4) amended April 5, 2023, p. A-1.
43 The term “service-connected” means, with respect to disability, that such disability was incurred or aggravated in the
line of duty in the active military, naval, air, or space service. VA determines whether veterans have service-connected
disabilities and, for those with such disabilities, assigns ratings from 0% to 100% based on the severity of the disability.
Percentages are assigned in increments of 10%.
44 VA is required to furnish hospital care and medical services to a veteran who is unable to defray the expenses of
necessary care as stipulated in law and regulations. 38 U.S.C. §1710(a)(2)(G); 38 U.S.C. §1722(a).
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resources permit.45 Most eligible veterans are required to formally enroll in VA’s health care
system to receive services.46 All enrolled veterans are offered a standard medical benefits
package, which includes (but is not limited to) inpatient and outpatient medical services,
pharmaceuticals, durable medical equipment, and prosthetic devices.47 In addition, VHA provides
long-term services and supports, and nursing home care to eligible veterans.
From time to time Congress has enacted legislation providing special treatment authorities for
certain groups of veterans. These special treatment authorities include health care for veterans
potentially exposed to toxic substances or environmental hazards during their military service.
The next section discusses these special treatment authorities, along with the three new categories
established by the Honoring our PACT Act of 2022 (P.L. 117-168) and amendments to existing
authorities made by the act, where applicable. Figure 1 provides a high-level overview of how
veterans will be eligible for VA health care under the eligibility criteria for toxic exposure or
deployment to a combat theater.
Health Care Eligibility for Toxic Exposures48
Current law provides eight separate criteria under which veterans potentially exposed to toxic
substances or environmental hazards during their military service may be eligible for VA health
care. In addition, combat theater veterans have an enhanced period of enrollment eligibility
during which veterans may receive care for medical conditions possibly related to their service. In
total, veterans are eligible for VA health care services through nine separate statutory eligibility
provisions (see Figure 1).
Vietnam-Era, Herbicide-Exposed Veterans49
In April 1970, Congress held the first of many hearings on the health effects of Agent Orange.50
Policymakers began to address the health concerns of Vietnam-era veterans in 1981 with the
passage of the Veterans’ Health Care, Training and Small Business Loan Act (P.L. 97-72). The act
granted Vietnam-era veterans’ priority status for health care at VA facilities by recognizing a
veteran’s own report of exposure as sufficient proof to receive medical care, unless there was
evidence to the contrary. This authority was further amended by the Veterans’ Health Care
Eligibility Reform Act of 1996 (P.L. 104-262). Under this authority, a veteran does not have to
demonstrate a link between a certain health condition and exposure to Agent Orange to be eligible
for medical care; instead, medical care is provided unless the VA determines that the condition
did not result from exposure to Agent Orange, or unless the condition has been identified by the
National Academy of Sciences (NAS) as having “limited/suggestive” evidence of no association
between the occurrence of the disease and exposure to a herbicide.51 According to the VA, “[T]he

45 38 U.S.C. §1710(a)(3).
46 38 U.S.C. §1705; 38 C.F.R. §17.36(a). In some cases, VA provides care to non-enrolled veterans in the following
classes: veterans who need treatment for a VA-rated service-connected disability, veterans who are VA rated as 50% or
more service-connected disabled, and veterans who were released from active duty within the previous 12 months for a
disability incurred or aggravated in the line of duty.
47 38 C.F.R. §17.38.
48 38 U.S.C. §1710(a)(2)(F) and (e).
49 38 U.S.C. §1710(e)(1)(A).
50 U.S. Congress, Senate, Committee on Commerce, Subcommittee on Energy, Natural Resources, and the
Environment, Effects of 2,4,5-T and Related Herbicides on Man and the Environment, 91st Cong., 2nd sess., April 7,
1970 (Washington: GPO, 1970).
51 “Limited/suggestive” evidence of no association is when several adequate studies, covering the full range of levels of
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determination of whether a Vietnam-era herbicide-exposed veteran’s disability may be related to
that exposure is strictly a clinical judgment to be made by the responsible physician (acting in
accordance with the guidelines issued by the Under Secretary of Health and [conditions identified
by the National Academy of Sciences].”52 Treatment authority authorized by P.L. 104-262 was
extended at various intervals by the Veterans Programs Enhancement Act of 1998 (P.L. 105-368)
and the Department of Veterans Affairs Health Care Programs Enhancement Act of 2001 (P.L.
107-135), until it was permanently authorized by the Caregivers and Veterans Omnibus Health
Services Act of 2010 (P.L. 111-163).
The Honoring our PACT Act of 2022 (P.L. 117-168) amended the definition of Vietnam‐era
herbicide‐exposed veteran to include the following:
Veterans who served on active military, naval, air, or space service53
• in the Republic of Vietnam during the period beginning on January 9, 1962, and
ending on May 7, 1975;
• in Thailand at any United States or Royal Thai base during the period beginning
on January 9, 1962, and ending on June 30, 1976, without regard to where on the
base the veteran was located or what military job specialty the veteran
performed;
• in Laos during the period beginning on December 1, 1965, and ending on
September 30, 1969;
• in Cambodia at Mimot or Krek, Kampong Cham Province during the period
beginning on April 16, 1969, and ending on April 30, 1969; or
• in Guam or American Samoa, or in the territorial waters thereof, during the
period beginning on January 9, 1962, and ending on July 31, 1980, or served on
Johnston Atoll or on a ship that called at Johnston Atoll during the period
beginning on January 1, 1972, and ending on September 30, 1977.
In addition, a veteran may be considered a Vietnam-era herbicide-exposed veteran if the VA
Secretary finds the veteran may have been exposed during active service to dioxin during the
Vietnam-era, regardless of the geographic area of such service, or was exposed during such
service to a toxic substance found in an herbicide or defoliant used for military purposes during
such era, regardless of the geographic area of such service.54
Veterans who have served active military, naval, air, or space service as specified above during
the Vietnam-era are eligible for hospital care, medical services, and nursing home care even if
there is insufficient medical evidence to conclude that such disability may be associated with
herbicide exposure. Such veterans are deemed ineligible in cases where VA determines that the
condition did not result from exposure to Agent Orange, or in cases where the condition has been
identified by NAS as having “limited/suggestive” evidence of no association between the
occurrence of the disease and exposure to a herbicide.55 Veterans are exempt from copayment and

exposure that human beings are known to encounter, are consistent in not showing a positive association between any
magnitude of exposure to herbicides and the outcome of disease.
52 Department of Veterans Affairs, “Third Party Billing for Medical Care Provided Under Special Treatment
Authorities,” 82 Federal Register 55548, November 22, 2017.
53 38 U.S.C. §1710(e)(4)(A) and 38 U.S.C. §1116(d). Also see Department of Veterans Affairs, Veterans Health
Administration, Eligibility Determination, VHA DIRECTIVE 1601A.02(6), amended March 6, 2024.
54 38 U.S.C. §1710(e)(4)(A).
55 38 U.S.C. §1710(e)(2)(A).
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third-party billing for hospital care, medical services, nursing home care, and medications
prescribed on an outpatient basis for any condition possibly associated with herbicide exposure.56
Under the provisions in the Honoring our PACT Act of 2022 (P.L. 117-168), Vietnam-era veterans
who served in the above-mentioned time periods and locations are eligible to enroll in the VA
health care system beginning October 1, 2022.57
Radiation-Exposed Veterans58
The Veterans’ Health Care, Training and Small Business Loan Act of 1981 (P.L. 97-72)
established eligibility for VA medical care for veterans whose conditions may have resulted from
radiation exposure on the same basis as eligibility as that provided for Vietnam-era, herbicide-
exposed veterans. The Veterans’ Health Care Eligibility Reform Act of 1996 (P.L. 104-262) made
permanent this authority for veterans exposed to radiation. Under this authority, veterans who
served on active duty and participated in a radiation-risk activity (see definition below),59 as well
as individuals who, while a member of a reserve component of the Armed Forces, participated in
a radiation-risk activity during a period of active duty for training or inactive-duty training, are
eligible for hospital care, medical services, and nursing home care for any presumptive disease
listed at 38 U.S.C. §1112(c)(2),60 or for any other disease for which that there is credible evidence
showing a positive association between the disease in humans and exposure to ionizing radiation,
as determined by the Secretary.61 Veterans are exempt from copayment and third-party billing for
hospital care, medical services, nursing home care, and medications prescribed on an outpatient
basis for any condition possibly associated with radiation exposure.62
The Honoring our PACT Act of 2022 (P.L. 117-168) amended the definition of “radiation-risk
activity” to include veterans who took part in the cleanup of Enewetak Atoll from January 1,
1977, through December 31, 1980; veterans who served in the cleanup of the collision of a U.S.
Air Force B-52 bomber over Palomares, Spain, from January 17, 1966, through March 31, 1967;
and veterans involved in the cleanup and decontamination effort of a B-52 bomber crash in Thule,
Greenland, from January 21, 1968, to September 25, 1968.63

56 38 C.F.R. §17.108.
57 Department of Veterans Affairs, “VA opens health care eligibility for Vietnam, Gulf War, post-9/11 Veterans under
PACT Act,” press release, September 28, 2022, https://www.va.gov/opa/pressrel/pressrelease.cfm?id=5826.
58 38 U.S.C. §1710(e)(1)(B).
59 38 U.S.C. §1112(c)(3)(B).
60 The diseases are the following: leukemia (other than chronic lymphocytic leukemia); cancer of the thyroid; cancer of
the breast; cancer of the pharynx; cancer of the esophagus; cancer of the stomach; cancer of the small intestine; cancer
of the pancreas; multiple myeloma; lymphomas (except Hodgkin’s disease); cancer of the bile ducts; cancer of the gall
bladder; primary liver cancer (except if cirrhosis or hepatitis B is indicated); cancer of the salivary gland; cancer of the
urinary tract; bronchiolo-alveolar carcinoma; cancer of the bone; cancer of the brain; cancer of the colon; cancer of the
lung; and cancer of the ovary.
61 38 U.S.C. §1710(e)(1)(B)(ii).
62 38 C.F.R. §17.108.
63 The United States conducted nuclear weapons detonation tests from 1948 to 1958 on Enewetak Atoll in the Marshall
Islands. Nearly 20 years after the nuclear weapons detonation tests had ended in 1958, U.S. military personnel
participated in the cleanup efforts on Enewetak Atoll beginning in 1977. This cleanup effort was referred to as the
Enewetak Radiological Support Project. On January 17, 1966, a U.S. Air Force B-52 bomber collided with its refueling
tanker, and four thermonuclear bombs fell near Palomares, Spain. Two of the bombs detonated and dispersed
plutonium. In another incident, on January 21, 1968, a fire on a U.S. Air Force B-52 bomber flying over Greenland
caused it to crash 7½ miles from Thule Base on the ice of North Star Bay. “The conventional high explosives in the B-
52’s four thermonuclear bombs went off, scattering radioactive debris over the ice, but there was no nuclear
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This expanded definition of “radiation-risk activity” includes the following:64
• Onsite participation in a test involving the atmospheric detonation of a nuclear
device (without regard to whether the nation conducting the test was the United
States or another nation).
• The occupation of Hiroshima or Nagasaki, Japan, by United States forces during
the period beginning on August 6, 1945, and ending on July 1, 1946.
• Internment as prisoner of war in Japan (or service on active duty in Japan
immediately following such internment) during World War II that (as determined
by the Secretary) resulted in potential exposure to ionizing radiation comparable
to that of veterans occupying Hiroshima or Nagasaki, Japan.
• Service in a capacity that, if performed as an employee of the Department of
Energy, would qualify the individual for inclusion as a member of the Special
Exposure Cohort under Section 3621(14) of the Energy Employees Occupational
Illness Compensation Program Act of 2000 (EEOICPA, 42 U.S.C. §7384l(14)).65
• Cleanup of Enewetak Atoll during the period beginning on January 1, 1977, and
ending on December 31, 1980.
• Onsite participation in the response effort following the collision of a U.S. Air
Force B-52 bomber and refueling plane that caused the release of four
thermonuclear weapons in the vicinity of Palomares, Spain, during the period
beginning January 17, 1966, and ending March 31, 1967.
• Onsite participation in the response effort following the on-board fire and crash
of a U.S. Air Force B-52 bomber that caused the release of four thermonuclear
weapons in the vicinity of Thule Air Force Base, Greenland, during the period
beginning January 21, 1968, and ending September 25, 1968.
Persian Gulf War Veterans66
As it did for Vietnam-era veterans exposed to Agent Orange, Congress passed, in 1993, P.L. 103-
210, which provides additional authority for VA to provide health care for veterans of the Persian
Gulf War.67 For these veterans, health care is provided for medical conditions possibly related to
exposure to toxic substances or environmental hazards during active duty service in the
Southwest Asia theater of operations during the Persian Gulf War.68 Veterans who served on
active duty between August 2, 1990, and November 11, 1998, in the Southwest Asia theater of
operations during the Persian Gulf War are eligible for hospital care, medical services, and

detonation.” (Sources: Foreign Relations of the United States, 1964–1968, vol. XII, Western Europe,
https://history.state.gov/historicaldocuments/frus1964-68v12/d1 and https://www.publichealth.va.gov/exposures/
radiation/sources/index.asp).
64 38 U.S.C. §1112(c)(3)(B).
65 For additional information on EEOICPA, see CRS Report R46476, The Energy Employees Occupational Illness
Compensation Program Act (EEOICPA).
66 38 U.S.C. §1710(e)(1)(C).
67 The term “Persian Gulf War” means “the period beginning on August 2, 1990, and ending on the date thereafter
prescribed by Presidential proclamation or by law” (38 U.S.C. §101(33)). Currently, no end date has been prescribed by
the President or Congress.
68 U.S. Congress, House Committee on Veterans’ Affairs, Priority VA Health Care for Persian Gulf War Veterans,
report to accompany H.R. 2535, 103rd Cong., July 29, 1993, H.Rept. 103-198.
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nursing home care for any disability, unless medical evidence is insufficient to conclude that such
disability might be associated with service in the Persian Gulf War.
Veterans are exempt from copayment and third-party billing for hospital care, medical services,
nursing home care, and medications prescribed on an outpatient basis for any condition possibly
associated with service in the Persian Gulf War.69
Combat-Theater Veterans70
In 1998, Congress—responding to growing concern over Persian Gulf War veterans’ undiagnosed
illnesses—passed the Veterans Programs Enhancement Act of 1998 (P.L. 105-368). The act
entitled veterans (including National Guard and reserve components) who served on active duty
in a theater of combat operations during a period of war71 after the Persian Gulf War to enroll in
VA health care during a two-year period following the date of discharge and to receive care, even
if medical evidence is insufficient to conclude that such illnesses are attributable to such service.
In 2007, the National Defense Authorization Act (NDAA; P.L. 110-181), FY2008, created a five-
year period of enrollment eligibility for veterans who served in a theater of combat operations
after November 11, 1998.72 The Clay Hunt Suicide Prevention for American Veterans Act (P.L.
114-2) authorized an additional one-year enrollment eligibility period for veterans who were
discharged from active duty after January 1, 2009, and before January 1, 2011, but who did not
enroll during the five-year period of post-discharge eligibility. This one-year period began on
February 12, 2015, the enactment date of the Clay Hunt Suicide Prevention for American
Veterans Act. It ended on February 12, 2016.73
The Honoring our PACT Act of 2022 (P.L. 117-168) amended the five-year period and extended it
to 10 years. In addition, the act further broadened the types of veterans who could qualify based
on service in the Persian Gulf War. Veterans who served between September 11, 2001, and
October 1, 2013, and were unable to enroll during the five-year period of post-discharge
eligibility (i.e., before October 1, 2022), received an additional one-year period of enrollment
eligibility starting October 1, 2022 (i.e., until September 30, 2023).74 Furthermore, the act
clarifies that service in the Persian Gulf War applies to any veteran who, during such period of
service, received the Armed Forces Expeditionary Medal, Service Specific Expeditionary Medal,
Combat Era Specific Expeditionary Medal, Campaign Specific Medal, or any other combat

69 38 C.F.R. §17.108.
70 38 U.S.C. §1710(e)(1)(D).
71 VA uses the term “a period of hostility”—“during a period of war after the Gulf War, or during a period of hostility
after November 11, 1998” Department of Veterans Affairs, Veterans Health Administration, Registration and
Enrollment, VHA DIRECTIVE 1601A.01(1), amended January 10, 2023, p. 14.
72 The Clay Hunt Suicide Prevention for American Veterans Act (P.L. 114-2) authorized an additional one-year period
of eligibility to enroll for those veterans who were discharged from active duty after January 1, 2009, and before
January 1, 2011, but who did not enroll during the five-year period of post-discharge eligibility. This one-year period
began on February 12, 2015, the enactment date of the Clay Hunt Suicide Prevention for American Veterans Act. It
ended on February 12, 2016. Expanded eligibility under the act was established in response to concerns that the five-
year special eligibility period was not an adequate amount of time for veterans seeking mental health treatment. U.S.
Congress, Senate Committee on Veterans’ Affairs, Clay Hunt Suicide Prevention for American Veterans Act, report to
accompany H.R. 203, 114th Cong., 1st sess., April 23, 2015, S.Rept. 114-34 (Washington: GPO, 2015), p. 9.
73 The expanded eligibility under the act was established in response to concerns that the five-year special eligibility
period was not an adequate amount of time for veterans seeking mental health treatment. U.S. Congress, Senate
Committee on Veterans’ Affairs, Clay Hunt Suicide Prevention for American Veterans Act, report to accompany H.R.
203, 114th Cong., 1st sess., April 23, 2015, S.Rept. 114-34 (Washington: GPO, 2015), p. 9.
74 The one-year period of enrollment eligibility ended on September 30, 2023.
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theater award established by a federal statute or an executive order. These amendments became
effective on October 1, 2022.75
In general, returning combat veterans are assigned to Priority Category 6, unless they are eligible
for placement in a higher enrollment priority category based on other eligibility criteria.76 These
veterans are eligible for hospital care, medical services, and nursing home care for any illness,
unless medical evidence is insufficient to conclude that such disability may be associated with
service in the Persian Gulf War. Veterans are not charged copays for medication or treatment of
conditions potentially related to their combat service.77 At the end of the 10-year period, veterans
enrolled in Priority Category 6 may be reenrolled in Priority Category 7 or 8, or a higher
enrollment priority category, depending on their service-connected disability status and income
level. Some may be required to make copayments for nonservice-connected conditions based on
copay requirements for Priority Category 7 and 8.78 The above criteria also apply to National
Guard and reserve personnel who were called to active duty by federal executive order and who
served in a theater of combat operations after November 11, 1998. The most recent discharge date
is used for servicemembers who have been called to duty multiple times.
Veterans Who Participated in Operation Shipboard Hazard and Defense
(SHAD)/Project 112 Tests79
Between 1962 and 1973, the Department of Defense (DOD) planned and conducted chemical and
biological warfare tests at the Deseret Test Center in Fort Douglas, UT. The testing program,
known as Project 112, included shipboard and land-based testing. Project Shipboard and Hazard
Defense (SHAD) was the shipboard part of these tests.80 According to DOD, “SHAD was
designed to test ships’ vulnerability to biological or chemical attack.”81 In response to health
concerns of veterans who were involved in Deseret Test Center tests, Congress passed the
Veterans Health Care, Capital Asset, and Business Improvement Act of 2003 (P.L. 108-170),
which authorized hospital care, medical services, and nursing home care for any illness, without a
requirement for service-connection.
Veterans are exempt from copayment and third-party billing for hospital care, medical services,
nursing home care, and medications prescribed on an outpatient basis for any condition possibly
associated with these chemical and biological tests.82

75 Department of Veterans Affairs, “VA opens health care eligibility for Vietnam, Gulf War, post-9/11 Veterans under
PACT Act,” press release, September 28, 2022, https://www.va.gov/opa/pressrel/pressrelease.cfm?id=5826.
76 38 U.S.C. §1705(a)(6). In general, most veterans are required to formally enroll in the VHA health care system to
receive services. Once a veteran is enrolled, the veteran remains in the system and does not have to reapply for
enrollment annually. Veterans are placed in one of eight priority enrollment categories or Priority Groups.
77 38 C.F.R. §17.108.
78 If veterans’ financial circumstances place them in Priority Group 8, they will be “grandfathered” into a Priority
Group 8a or Priority Group 8c, and their enrollment in VA will be continued, regardless of the date of their original VA
application. Also see Department of Veterans Affairs, Veterans Health Administration, Registration and Enrollment,
VHA DIRECTIVE 1601A.01(1), amended April 4, 2024.
79 38 U.S.C. §1710(e)(1)(E).
80 U.S. Congress, House Committee on Veterans’ Affairs, Health Care for Veterans of Project 112/Project Shad Act of
2003, report to accompany H.R. 2433, 108th Cong., 1st sess., July 16, 2003, p. 8.
81 Ibid.
82 38 C.F.R. §17.108.
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Camp Lejeune Veterans83
In response to potential health effects of contaminated water at the Marine base at Camp Lejeune,
NC, Congress passed the Honoring America’s Veterans and Caring for Camp Lejeune Families
Act of 2012 (P.L. 112-154), as amended by the Consolidated and Further Continuing
Appropriations Act, 2015 (P.L. 113-235, Division I, Title II, Section 243).84 This act established a
presumptive service-connection for veterans’ health care for one or more of 15 diseases and
health conditions that may be associated with exposure to trichloroethylene (TCE),
tetrachloroethylene (PCE), vinyl chloride, and other contaminants discovered in drinking water
supplies at Camp Lejeune. Veterans and their family members who worked or lived at Camp
Lejeune for no less than 30 days (consecutive or nonconsecutive) from August 1, 1953, to
December 31, 1987, generally are eligible for VA health care services under this law. Eligible
veterans and family members can receive free care for any of the 15 covered illnesses or
conditions.85 To be eligible, a veteran or former reservist or member of the National Guard (1)
must have been stationed at Camp Lejeune, or traveled to Camp Lejeune as part of his or her
professional duties, and (2) must have served on active duty for at least 30 days (consecutive or
nonconsecutive) during the period beginning on August 1, 1953, and ending on December 31,
1987.

83 38 U.S.C. §1710(e)(1)(F).
84 To read the studies conducted about the contamination, see https://www.atsdr.cdc.gov/sites/lejeune/health-
effects.html.
85 A covered illness or condition incudes any of the following: esophageal cancer; lung cancer; breast cancer; bladder
cancer; kidney cancer; leukemia; multiple myeloma; myelodysplastic syndromes; renal toxicity; hepatic steatosis;
female infertility; miscarriage; scleroderma; neurobehavioral effects; and Non-Hodgkin’s lymphoma (38 U.S.C.
§1710(e)(1)(F); 38 C.F.R. §17.400).
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Figure 1. High-Level Overview of Eligibility Pathways for Toxic Exposed Veterans

Source: Figure prepared by CRS based on 38 U.S.C. §§1710(e)(1)(A), 1710(e)(1)(B), 1710(e)(1)(C), 1710(e)(1)(D), 1710(e)(1)(E), 1710(e)(1)(F), 1710(e)(1)(G),
1710(e)(1)(H), and 1710(e)(1)(I), and 38 C.F.R. §17.400.
CRS-16

Notes: Combat Theater Veterans: Veterans who served on active duty in a theater of combat operations during a period of war after the Persian Gulf War,
including those who received the Armed Forces Expeditionary Medal, Service Specific Expeditionary Medal, Combat Era Specific Expeditionary Medal, Campaign Specific
Medal, or any other combat theater award established by a federal statute or an executive order; or in combat against a hostile force during a period of hostilities after
November 11, 1998, and who were discharged between September 11, 2001, and October 1, 2013, and were unable to enrol in the VA health care system before
October 1, 2022, were eligible to enrol in the VA health care system during a special enrol ment period that began on October 1, 2022, and ended on September 30,
2023. All other combat theater veterans are eligible for enrol ment in VA health care within a 10-year period from date of discharge or release. Once enrol ed, veterans
would remain enrol ed in the VA health care system, and enrol ed veterans may seek care at any VA facility and do not need to reestablish eligibility for enrol ment
purposes.
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Veterans Who Participated in a Toxic Exposure Risk Activity (TERA)86
The Honoring our PACT Act of 2022 (P.L. 117-168) amends current law and authorizes hospital
care (including mental health services and counseling), medical services, and nursing home care
to veterans who participated in a “toxic exposure risk activity”87 while serving on active duty,
active duty for training, or inactive duty training. In these cases, health care is authorized for any
illness, unless medical evidence is insufficient to conclude that the condition is attributable to
such service. The term toxic exposure risk activity means a record in an exposure tracking system
indicating that the veteran carried out the activity; or where the VA determines that it is
“reasonably prudent” to provide care and services to a veteran to protect the health of such
veteran. The tracking system means a system, program, or pilot program used by VA or DOD to
track how veterans or members of the Armed Forces have been exposed to various occupational
or environmental hazards; and also includes the Individual Longitudinal Exposure Record
(ILER), or successor system (see Figure 2).88
Veterans are exempt from copayment and third-party billing for hospital care, medical services,
nursing home care, and medications prescribed on an outpatient basis for any condition possibly
associated with a toxic exposure risk activity.
Under the Honoring our PACT Act of 2022, the Secretary is required to implement the phase-in
enrollment of veterans who participated in a toxic exposure risk activity as follows:89
• October 1, 2024, for veterans who were discharged or released from the active
military, naval, air, or space service during the period beginning on August 2,
1990, and ending on September 11, 2001;
• October 1, 2026, for veterans who were discharged or released from the active
military, naval, air, or space service during the period beginning on September
12, 2001, and ending on December 31, 2006;
• October 1, 2028, for veterans who were discharged or released from the active
military, naval, air, or space service during the period beginning on January 1,
2007, and ending on December 31, 2012; and
• October 1, 2030, for veterans who were discharged or released from the active
military, naval, air, or space service during the period beginning on January 1,
2013, and ending on December 31, 2018.
The Secretary may revise these phase-in dates based on the number of veterans seeking care and
the available resources. When modifying the dates, the Secretary must notify the Senate and
House Committees on Veterans’ Affairs of the proposed modification and publish a notice with
the modified date in the Federal Register (see section on “Elimination of the Phase-In Dates for
New Cohorts of Toxic Exposed Veterans”).
Veterans Who Served in a Specific Duty Station90
The Honoring our PACT Act of 2022 (P.L. 117-168) amends current law and authorizes VA to
provide hospital care (including mental health services and counseling), medical services, and

86 38 U.S.C. §1710(e)(1)(G).
87 38 U.S.C. §1710(e)(4)(C).
88 38 U.S.C. §1710(e)(4)(C) and 38 U.S.C. §1119(c)(2).
89 38 U.S.C. §1710(e)(6)(A).
90 38 U.S.C. §1710(e)(1)(H).
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nursing home care for any illness, unless medical evidence is insufficient to conclude that the
condition is attributable to such service. The provision of this care is authorized for any veteran
based on active duty in specific locations, which are broken out into two categories (see Figure
2).
Under the first category, eligibility would be granted to any veteran who on or after August 2,
1990, performed active military, naval, air, or space service while assigned to a duty station in the
following locations (including the air space above): Bahrain, Iraq, Kuwait, Oman, Qatar, Saudi
Arabia, Somalia, or the United Arab Emirates.
Under the second category, eligibility would be granted to any veteran who on or after September
11, 2001, performed active military, naval, air, or space service while assigned to a duty station
(including the air space above) in the following locations: Afghanistan, Djibouti, Egypt, Jordan,
Lebanon, Syria, Yemen, Uzbekistan, the Philippines, or any other country determined relevant by
the Secretary.
Veterans are exempt from copayment and third-party billing for hospital care, medical services,
nursing home care, and medications prescribed on an outpatient basis for any condition possibly
associated with service in these locations.
Under the Honoring our PACT Act of 2022, the Secretary is required to implement the phase-in
enrollment of veterans who were stationed at a specific duty station location as follows:91
• October 1, 2024, for veterans who were discharged or released from the active
military, naval, air, or space service during the period beginning on August 2,
1990, and ending on September 11, 2001;
• October 1, 2026, for veterans who were discharged or released from the active
military, naval, air, or space service during the period beginning on September
12, 2001, and ending on December 31, 2006;
• October 1, 2028, for veterans who were discharged or released from the active
military, naval, air, or space service during the period beginning on January 1,
2007, and ending on December 31, 2012; and
• October 1, 2030, for veterans who were discharged or released from the active
military, naval, air, or space service during the period beginning on January 1,
2013, and ending on December 31, 2018.
The Secretary may revise these phase-in dates based on the number of veterans seeking care and
the available resources. When modifying the dates, the Secretary must notify the Senate and
House Committees on Veterans’ Affairs of the proposed modification and publish a notice with
the modified date in the Federal Register (see section on “Elimination of the Phase-In Dates for
New Cohorts of Toxic Exposed Veterans”).
Veterans Deployed in Support of Contingency Operations92
The Honoring our PACT Act of 2022 (P.L. 117-168) amends current law and authorizes VA to
provide hospital care (including mental health services and counseling), medical services, and
nursing home care for any illness, unless medical evidence is insufficient to conclude that the

91 38 U.S.C. §1710(e)(6)(A).
92 38 U.S.C. §1710(e)(1)(I).
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condition is attributable to such service. The provision of this care is authorized for veterans who
were deployed for any of the following contingency operations (see Figure 2):93
• Operation Enduring Freedom,
• Operation Freedom’s Sentinel,
• Operation Iraqi Freedom,
• Operation New Dawn,
• Operation Inherent Resolve, or
• Resolute Support Mission.
Under the Honoring our PACT Act of 2022, the Secretary is required to implement the phase-in
enrollment of veterans based on “contingency operations” on October 1, 2032. The Secretary may
revise this phase-in date based on the number of veterans seeking care and the available
resources. When modifying the dates, the Secretary must notify the Senate and House
Committees on Veterans’ Affairs of the proposed modification and publish a notice with the
modified date in the Federal Register (see section on “Elimination of the Phase-In Dates for New
Cohorts of Toxic Exposed Veterans”).
Figure 2. Expansion of Health Care for Specific Categories of Toxic-Exposed
Veterans and Veterans in Specific Contingency Operations with Statutory
Phase-In Dates

Source: Figure prepared by CRS based on 38 U.S.C. §1710(e)(1)(G), (H), and (I) and 38 U.S.C. §1710(e)(6).
Notes: VA Secretary could modify the enrol ment eligibility dates to an earlier date based on available resources
and number of veterans receiving care.

93 For details and dates of these contingency operations, see CRS Report RS21405, U.S. Periods of War and Dates of
Recent Conflicts.
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Elimination of the Phase-In Dates for New Cohorts of Toxic
Exposed Veterans
As authorized by Section 103 of the Honoring our PACT Act of 2022, for the Secretary to revise
the phase-in dates, on February 26, 2024, VA announced that it intends to eliminate the phase-in
dates established by the Honoring our PACT Act of 2022, and would begin accepting applications
for enrollment in the VA health care system of all eligible veterans.94 On March 5, 2024, VA
published a notice and provided sub-regulatory guidance in the Federal Register95 that beginning
March 5, 2024, VA would process applications for enrollment in the VA health care system of
veterans who participated in a Toxic Exposure Risk Activity (TERA),96 who served in a specific
duty station during specific periods of time,97 or who were deployed in support of specific
contingency operations (see Figure 3).98
According to VA’s sub-regulatory guidance, to be eligible under the TERA category, veterans
during active duty, active duty for training, or inactive duty training should have been exposed to
one or more of the following:
air pollutants (burn pits, sand, dust, particulates, oil well fires, sulfur fires), chemicals
(pesticides, herbicides, depleted uranium with embedded shrapnel, contaminated water),
occupational hazards (asbestos, industrial solvents, lead, paints including chemical agent
resistant coating, firefighting foams), radiation (nuclear weapons handling, maintenance
and detonation, radioactive material, calibration and measurement sources, X-rays,
radiation from military occupational exposure), and warfare agents (nerve agents, chemical
and biological weapons).99
This could be determined by an entry in the Individual Longitudinal Exposure Record (ILER) or
if the Veterans Benefits Administration (VBA) has previously determined that the veteran
participated in a TERA based on a disability compensation determination.100 Additionally,
veterans could identify any potential TERA when applying for health care enrollment, and VA
would make a determination of their eligibility based on records in Veterans Benefits
Management System (VBMS) TERA Memorandum Tool maintained by VBA, Veterans
Information Solution (VIS), among other sources.101 Moreover, if veterans submit evidence of

94 Department of Veterans Affairs, “In one of the largest-ever expansions of Veteran health care, all Veterans exposed
to toxins and other hazards during military service – at home or abroad – will be eligible for VA health care beginning
March 5,” press release, February 26, 2024, https://news.va.gov/press-room/veteran-toxins-hazards-serving-eligible-va/
(accessed April 10, 2024).
95 Department of Veterans Affairs, “Processing Applications for Health Care, Sergeant First Class Heath Robinson
Honoring Our Promise to Address Comprehensive Toxics Act of 2022, or the Honoring Our PACT Act of 2022,” 89
Federal Register 15753-15754, March 5, 2024.
96 38 U.S.C. §1710(e)(1)(G).
97 38 U.S.C.§1710(e)(1)(H).
98 38 U.S.C. §1710(e)(1)(I).
99 Department of Veterans Affairs, Office of the Under Secretary for Health, Accelerated Implementation of Section
103(a) of the Honoring our PACT Act of 2022, Memorandum to VISN Directors, Medical Center Directors, February
22, 2024, p. 4.
100 Department of Veterans Affairs, “Processing Applications for Health Care, Sergeant First Class Heath Robinson
Honoring Our Promise to Address Comprehensive Toxics Act of 2022, or the Honoring Our PACT Act of 2022,” 89
Federal Register 15753-15754, March 5, 2024.
101 Department of Veterans Affairs, Office of the Under Secretary for Health, Accelerated Implementation of Section
103(a) of the Honoring our PACT Act of 2022, Memorandum to VISN Directors, Medical Center Directors, February
22, 2024, p. 5.
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participation in a TERA, VA’s medical facility enrollment staff must submit that evidence to VBA
to make a determination.102
When determining eligibility based on specific duty station during specific periods of time,103 or
deployment in support of specific contingency operations,104 VA would review the veteran’s
Certificate of Release or Discharge from Active Duty (DD Form 214)105 or search VIS and
VBMS to verify the veteran’s military service in a theater of combat operations or location with
corresponding periods of service or deployment in support of contingency operations defined in
Section 103 of the Honoring our PACT Act of 2022.106

102 Department of Veterans Affairs, Office of the Under Secretary for Health, Accelerated Implementation of Section
103(a) of the Honoring our PACT Act of 2022, Memorandum to VISN Directors, Medical Center Directors, February
22, 2024, p. 6.
103 38 U.S.C.§1710(e)(1)(H).
104 38 U.S.C. §1710(e)(1)(I).
105 The DD Form 214 is a military service document and “provides a service member’s complete and verified military
service record (Active and Reserve), awards and medals, and other pertinent service information, such as highest
rank/rate and pay grade held on active duty, total military combat service and/or overseas and Military Occupational
Specialty (MOS) / Area of Concentration (AOC).” Source: Department of Defense, Department of The Army, Issuance
of DD Form 214 (Certificate of Release or Discharge from Active Duty) for Army Reserve Soldiers Not Processed by a
Military Installation Transition Point, and DD Form 215 (Correction to DD Form 214), Memorandum, July 15, 2021.
106 Department of Veterans Affairs, Office of the Under Secretary for Health, Accelerated Implementation of Section
103(a) of the Honoring our PACT Act of 2022, Memorandum to VISN Directors, Medical Center Directors, February
22, 2024, p. 4.
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Figure 3. Health Care for Specific Categories of Toxic-Exposed Veterans and
Veterans in Specific Contingency Operations with Modified Phase-In Date of March
5, 2024

Source: Figure prepared by CRS based on 38 U.S.C. §1710(e)(1)(G), (H), and (I) and 38 U.S.C. §1710(e)(6), and
Department of Veterans Affairs, “Processing Applications for Health Care, Sergeant First Class Heath Robinson
Honoring Our Promise to Address Comprehensive Toxics Act of 2022, or the Honoring Our PACT Act of
2022,” 89 Federal Register 15753-15754, March 5, 2024.
Toxic Exposure Screenings of Veterans
Section 603 of the Honoring our PACT Act of 2022 (P.L. 117-168) mandated that VHA
implement toxic exposure screenings to identify veterans enrolled in the VA health care system
with potential toxic exposures during military, naval, air, or space service as part of their health
care screenings. The act mandated that the department implement this requirement by November
8, 2022.107 The law also required that enrolled veterans must be screened at least once every
five years. The Secretary is required to consider updating the screening tool at least biennially to
ensure that it contains the most current information. According to VA, “Veterans who are not
enrolled and who meet eligibility requirements will have an opportunity to enroll and receive the
screening,”108 and information gathered during the toxic exposure screening will be included in

107 Department of Veterans Affairs, “Tomorrow, all Veterans enrolled in VA health care will be eligible for new toxic
exposure screenings,” press release, November 7, 2022, https://www.va.gov/opa/pressrel/pressrelease.cfm?id=5838.
108 U.S. Congress, Senate Committee on Veterans’ Affairs, Hearing on the Department of Veterans Affairs
Implementation of the SFC Heath Robinson Honoring our PACT Act, statement of Shereef Elnahal, Under Secretary
for Health, and Joshua Jacobs, Senior Advisor for Policy, “Performing The Delegable Duties of the Under Secretary
For Benefits Department of Veterans Affairs,” 117th Cong., November 16, 2022.
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veterans’ electronic health records and be used to connect them with applicable VA benefits and
services.109
Prior to implementing the screening tool across VA medical centers and clinics nationwide, VHA
piloted the toxic exposure screening tool at 13 medical facilities. Based on feedback from the
pilot sites, VHA revised the screening tool before deploying it to all VA health care facilities.
During the initial phases, the toxic exposure screening will be administered either during or
outside of primary care appointments. When conducted during a primary care appointment, the
screening would be conducted by a licensed practical nurse (LPN) on the veteran’s care team110 or
by the primary care provider. When conducted outside of the primary care appointment, the
screening would be conducted by the appropriate non-primary care staff member. For veterans
who are not assigned to a primary care team, or who wish to be screened sooner, the screening
would be completed by a Toxic Exposure Screening (TES) Navigator.111
The screening tool is included in VHA’s Computerized Patient Record System (CPRS) and
appears as a clinical reminder to VHA providers (see example of first screen in Figure 4).

109 Department of Veterans Affairs, Veterans Health Administration, “Agency Information Collection Activity: Veteran
Toxic Exposure Screening Tool (PACT Act),” 87 Federal Register 72594-72595, November 11, 2022.
110 Generally, veterans enrolled in the VA health care system are assigned to a primary care team known as a Patient
Aligned Care Team (PACT). The team is composed of a primary care provider (doctor, nurse practitioner, or
physician’s assistant), clinical pharmacist, registered nurse (RN), and licensed practical nurse (LPN) or medical
assistant. See https://www.patientcare.va.gov/primarycare/pact/Resources.asp.
111 U.S. Congress, House Committee on Veterans’ Affairs, Hearing on Fulfilling our Pact: Ensuring Effective
Implementation of Toxic Exposure Legislation, statement of Shereef Elnahal, Under Secretary for Health, and Joshua
Jacobs, Senior Advisor for Policy, “Performing the Delegable Duties of the Under Secretary for Benefits Department of
Veterans Affairs,” 117th Cong., December 7, 2022.
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Figure 4. Toxic Exposure Screening Tool Clinical Reminder

Source: Department of Veterans Affairs, Toxic Exposure Screening Workflow Updates, Briefing to
Congressional Staff, October 14, 2022.
Notes: This is a screenshot of the Toxic Exposure Screening clinical reminder window that appears in
Computerized Patient Record System (CPRS). Based on a veteran’s exposure concern, several additional screens
are triggered to be completed by the provider/Exposure Screening (TES) navigator.
The screening would include three questions, as outlined in the text box below:
Toxic Exposure Screening (TES) Tool
Q. Do you believe you experienced any toxic exposures, such as Open Burn Pits/Airborne Hazards, Gulf War-
related exposures, Agent Orange, radiation, contaminated water at Camp Lejeune, or other such exposures while
serving in the Armed Forces?”
•
Yes
•
No
•
Don’t Know
•
Declines Screening
Q. If Yes, do you believe you were exposed to any of the fol owing while serving in the Armed Forces?
•
Open Burn Pits/Airborne Hazards,
•
Gulf War-related exposures
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•
Agent Orange
•
Radiation
•
Contaminated water at Camp Lejeune
•
Other exposures
Q. Does the Veteran or caregiver have fol ow-up questions?
•
Health/Medical Questions
•
Benefits/Claims Questions
•
VA Health Care Enrol ment and Eligibility Questions
•
Registry Questions
•
No questions at this time
Source: Department of Veterans Affairs, Toxic Exposure Screening Workflow Updates, Briefing to Congressional
Staff, October 14, 2022, and U.S. Congress, House Committee on Veterans' Affairs, Hearing on Fulfilling our Pact:
Ensuring Effective Implementation of Toxic Exposure Legislation, statement of Shereef Elnahal, Under Secretary for
Health, and Joshua Jacobs, Senior Advisor for Policy, “Performing The Delegable Duties of the Under Secretary
For Benefits Department of Veterans Affairs,” 117th Cong., December 7, 2022.
As shown in Figure 5, if a veteran responds “YES” to potential exposure questions, all “YES”
responses will be forwarded to the veteran’s primary care provider for follow up within 14 days.
If the veteran has not been assigned to a primary care team, the Toxic Exposure Screening
Navigators would follow-up by providing additional assistance, such as assigning the veteran to a
primary care team (with the veteran’s consent) and referring the veteran to additional information,
such as exposure-related benefits.
If the screening is performed by a veteran’s primary care provider, and the veteran indicates a
concern pertaining to the toxic exposure, a suspected toxic exposure diagnosis code would be
added to the problem list in the CPRS for future reference, and appropriate clinical assessments
will be conducted and documented. Veterans would also be provided with information on
exposure-related benefits, such as information on presumptive service-connected conditions
related to toxic exposures and health care registries.112
If a veteran responds “NO” to potential exposure questions, the veteran would be given a handout
with relevant information and told to follow up with their health care team if any health concerns
occur before the next toxic exposure screening in five years.113
Veterans who respond “I Don’t Know” to the environmental exposure questions would be asked
if they have any other health care concerns, which would also be documented; however, the toxic
exposure diagnosis code would not be added to the CPRS, and those veterans would be screened

112 VA maintains several health registries that provide special health examinations and health-related information to
veterans who may have been potentially exposed to environmental hazards during service. The registries include the
Airborne Hazards and Open Burn Pit Registry; the Gulf War Registry; the Depleted Uranium Follow-Up Program; the
Toxic Embedded Fragment Surveillance Center; the Agent Orange Registry; and the Ionizing Radiation Registry.
Certain veterans can participate in a VA health registry and receive free medical examinations, including laboratory
and other diagnostic tests deemed necessary by an examining clinician. See https://www.publichealth.va.gov/
exposures/publications/military-exposures/meyh-4/registry.asp. Additional resources for veterans can be found at
https://news.va.gov/109115/spread-word-pact-act-health-care-eligibility/.
113 U.S. Congress, House Committee on Veterans’ Affairs, Hearing on Fulfilling our Pact: Ensuring Effective
Implementation of Toxic Exposure Legislation, Statement of Shereef Elnahal, Under Secretary For Health and Joshua
Jacobs, Senior Advisor For Policy, Performing The Delegable Duties of the Under Secretary For Benefits Department
of Veterans Affairs, 117th Cong., December 7, 2022.
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again within one year.114 If a veteran declines screening, relevant information would be provided
to the veteran, and the veteran would be scheduled for screening again in one year.115
Figure 5. Overview of Toxic Exposure Screening Workflow

Source: Figure prepared by the Congressional Research Service, based on Department of Veterans Affairs,
Toxic Exposure Screening Workflow Updates, Briefing to Congressional Staff, October 14, 2022, and U.S.
Congress, House Committee on Veterans’ Affairs, Hearing on Fulfil ing our Pact: Ensuring Effective
Implementation of Toxic Exposure Legislation, Statement of Shereef Elnahal, Under Secretary for Health, and
Joshua Jacobs, Senior Advisor for Policy, “Performing The Delegable Duties of the Under Secretary For Benefits
Department of Veterans Affairs,” 117th Congress, December 7, 2022.

114 U.S. Congress, House Committee on Veterans’ Affairs, Hearing on Fulfilling our Pact: Ensuring Effective
Implementation of Toxic Exposure Legislation, Statement of Shereef Elnahal, Under Secretary for Health, and Joshua
Jacobs, Senior Advisor for Policy, “Performing The Delegable Duties of the Under Secretary For Benefits Department
of Veterans Affairs,” 117th Cong., December 7, 2022.
115 U.S. Congress, House Committee on Veterans’ Affairs, Hearing on Fulfilling our Pact: Ensuring Effective
Implementation of Toxic Exposure Legislation, Statement of Shereef Elnahal, Under Secretary for Health, and Joshua
Jacobs, Senior Advisor for Policy, “Performing The Delegable Duties of the Under Secretary For Benefits Department
of Veterans Affairs,” 117th Cong., December 7, 2022.
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Honoring our PACT Act Performance Dashboard
In March 2023, VA announced that it would be publishing a bi-weekly performance dashboard
showing key data indicators related to the Honoring our PACT Act.116 Additionally, since
September 2023, VA provides a quarterly demographic analysis of Honoring our PACT Act
related benefits, and since November 10, 2023, provides state-by-state data and congressional
district data on a monthly basis.117

Author Information

Sidath Viranga Panangala

Specialist in Veterans Policy

Acknowledgments
Jamie L. Hutchinson and Mari Lee, CRS Visual Information Specialists, prepared the figures in this report.

Disclaimer
This document was prepared by the Congressional Research Service (CRS). CRS serves as nonpartisan
shared staff to congressional committees and Members of Congress. It operates solely at the behest of and
under the direction of Congress. Information in a CRS Report should not be relied upon for purposes other
than public understanding of information that has been provided by CRS to Members of Congress in
connection with CRS’s institutional role. CRS Reports, as a work of the United States Government, are not
subject to copyright protection in the United States. Any CRS Report may be reproduced and distributed in
its entirety without permission from CRS. However, as a CRS Report may include copyrighted images or
material from a third party, you may need to obtain the permission of the copyright holder if you wish to
copy or otherwise use copyrighted material.

116 Department of Veterans Affairs, “VA releases dashboard to measure the PACT Act’s impact on Veterans and
survivors,” press release, March 3, 2023, https://news.va.gov/116652/va-releases-dashboard-measure-pact-act/.
117 VA, “PACT Act Performance Dashboard,” https://department.va.gov/pactdata/.
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